Manufacturing consensus: clinical guidelines

Yet these and other guidelines continue to be followed despite concerns about bias, because “We like to stick within the standard of care, because when the shit hits the fan we all want to be able to say we were just doing what everyone else is doing—even if what everyone else is doing isn’t very good.” – Jeanne Lenzer

On 13 April 1990, in an unprecedented action, the US National Institutes of Health faxed a letter to every physician in the US on how to correctly prescribe a breakthrough treatment for acute spinal cord injury. Many neurosurgeons were sceptical of the evidence that lay behind the new recommendation to give high dose steroids, yet when two respected organisations released a review and a guideline recommending the treatment, they felt obliged to give it. Now, over two decades later, new guidelines warn against the serious harms of high dose steroids. This case and others like it point to the ethical difficulties that doctors face when biased guidelines are promoted and raise the question: why do processes intended to prevent or reduce bias fail?

Doctors who are sceptical about the scientific basis of clinical guidelines have two choices: they can follow guidelines even though they suspect doing so will cause harm, or they can ignore them and do what they believe is right for their patients, thereby risking professional censure and possibly jeopardising their careers. This is no mere theoretical dilemma; there is evidence that even when doctors believe a guideline is likely to be harmful and compromised by bias, a substantial number follow it.

A poll of over 1000 neurosurgeons showed that only 11% believed the treatment was safe and effective. Only 6% thought it should be a standard of care. Yet when asked if they would continue prescribing the treatment, 60% said that they would. Many cited a fear of malpractice if they failed to follow “a standard of care.”

That standard was reversed this March, when the Congress of Neurological Surgeons issued new guidelines. The congress found that, “There is no Class I or Class II medicine evidence supporting the benefit of [steroids] in the treatment of acute [spinal cord injury]. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death.”

Guidelines are usually issued by large panels of authors representing specialty and other professional organisations. While it might seem difficult to bias a guideline with so many experts participating under the sponsorship of large professional bodies, a worrying number of cases suggests that it may be common.

Biased guidelines can have powerful and wide ranging effects. Thousands of guidelines have been issued, and, when promulgated by highly respected professional societies, they sometimes serve as de facto “standards of care” that may be used to devise institutional protocols, to develop measures of physician performance, and for insurance coverage decisions.

Guidelines may influence the medicines selected for inclusion on drug formularies and may be used as a “reliable authority” to support expert testimony in malpractice suits. Eighty four per cent of doctors say they are concerned about industry influence over clinical guidelines, yet the fear of malpractice suits puts many in an untenable position of following guidelines they believe are flawed or dangerous to patients.

Despite repeated calls to prohibit or limit conflicts of interests among guideline authors and their sponsors, most guideline panellists have conflicts, making the guidelines they issue less than reliable.

For all guidelines, the overwhelming majority of committee chairs and cochairs have ties to industry, and selection of panelists with desired viewpoints can make a wished for outcome a foregone conclusion. Committee stacking may be one of the most powerful and important tools to achieve a desired outcome. In response to a question about whether any known sceptics were invited to be on the committee, a spokesperson for the American Academy of Neurology said, “A potential panel member’s opinion on a topic does not determine eligibility for participation on an American Academy of Neurology guideline author panel. The guideline development process is evidence based.”

JC comments: For the past several years, I have been following the topic of consensus clinical guidelines and the conflict of interest issue in pharmacology and clinical medicine. There are some interesting parallels and differences with the climate science-policy interface. The issues are much starker in the context of clinical guidelines: life and death situations vs malpractice lawsuits. Common themes are cherry picking of data, stacking of committees, conflicts of interest and other sources of bias.

While the medical community has been grappling with these issues for decades (arguably with mixed success), the climate community has only begun grappling with these issues in the wake of climategate. Conflict of interest recommendations made by the InterAcademy Council are being addressed by the IPCC in a minimal way.

The lesson for climate scientists is that the consensus can be wrong, and many scientists will go along with it to avoid censure by their peers. The conflict of interest issues for climate science are far more complex and less easily identified than the financial conflicts existing in the medical field. Regardless of the presence or not of formally defined conflicts of interest, scientists need to continually challenge their assumptions to avoid bias.

129 responses to “Manufacturing consensus: clinical guidelines”

I am probably going to have difficulty expressing my idea. But in the case of medicine, as is the case in law, there is such a thing as an “authority”; a group of people, who, under law, are required to issue guidelines to be followed by the practionishoners who come under their jurisdiction.

In the case of law, the siutuation is quite clear. Elected officials pass the laws, and the judges then say what the law means. These statements are binding on all who practice law. In the case of medicine, things are far from clear. Judgements have to be made as to what is the best thing to do, and these judgements can be wrong.

In the case of sceince, things are completely clear. There is NO “authority”; none whatsoever. The empirical data is the Supreme Court of Science. So a consensus in science, not based on overwhelming empirical data, is an oxymoron.

Yes. You describe the difference that is lost on most of modernity between empirical truth (subset is scientific) and historical/legal or social truth. The former appeals to common observation as it’s source of truth. The latter appeals to consensus in various forms. At this point in time, if we had to depend on the former for the content of public discussion in all fields, climate being chief in this regard, we’d be shocked by the degree of relative quiet.

Jim, I really like what you wrote!
Except, I would say Judges and Juries.
The top level is Judges.
A law is really a law when it survives in court.
For Science and Engineering, WE DO WANT THE ACTUAL DATA.

I would love to discuss this, but it is so off topic. Let me just note the Juries do NOT come under the jurisdiciton of the Judges; that is why I did not mention them. You may not be familiar with the Henry Morganthaler abortion cases in Canada, but his second trial showed WHY juries do not come under the jurisdiction of any judge. My email address is bf906@ncf.ca

Thanks, Jim. Your last paragraph reminded me of Michael Crichton’s comment in the Caltech Michelin Lecture on 17 January 2003:

“Let’s be clear: the work of science has nothing whatever to do with consensus. Consensus is the business of politics. Science, on the contrary, requires only one investigator who happens to be right, which means that he or she has results that are verifiable by reference to the real world. In science consensus is irrelevant. What is relevant is reproducible results. The greatest scientists in history are great precisely because they broke with the consensus.”

omanuel, suppose you have 17 investigators each claiming to be right. each with completely different claims. By what process do you propose to determine which is “the one investigator who happens to be right?”

Unless you have a foolproof process for this problem, we’re looking at a fundamental flaw in Crichton’s line of reasoning here.

I would be fascinated to see a serious defense of Crichton’s reasoning here. The lack of such a defense put Crichton’s argument near the bottom of the pile of skeptical science rubbish. Richard Lindzen has far better arguments.

It’s much simpler than that. What gets rewarded gets repeated. What gets punished tends to go away. In the medical example failure to follow protocols get punished. In the arena of climate science, what gets rewarded is research that supports consensus.

The comparison between clinical guidelines and climatology is apt. Both suffer from the fact that we are herd animals who, when faced with having to chose between what the herd does and what is correct or rational but might be different, we usually chose the herd response. This is particularly true when there are additional possible benefits such as immediate accolade or profit for the individual making the choice.

I remember ten years ago or so when they used total cholesterol as the basis to prescribe statins. Then they switched to LDL which is not actually measured but estimated. The new guidelines resulted in many more people on statins. Even children were being put on them. I resisted as I was just barely over the guideline and had heard a colleague say he got bad leg pains from statins. Then I looked into the formula they used to estimate LDL and saw that my very low healthy triglycerides led to a higher estimate of LDL. Now many years later they finally have changed the guidelines so that people with my LDL are only put on statins if there is a family history of heart disease and other risk factors. But each time they have a new guideline, it is “settled” science and best practices but just by doing a little research on my own I could see the limits of what they really knew.

An early and influential study showed decreased cardio-vascular mortality by lowering cholesterol, and from that the mania for statins developed apace. Forgotten in the mad rush for profits, and to be ‘doing something’ for the arteries and the cardia, was the finding that overall mortality was not changed.

Cholesterol is a more important regulator in the human body than CO2 is in the climate. Uh, well, it seems so.
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Mmmm – I’m on statins and my LDL is very low, about 1.5. No pre-disposing familial history (that I’m aware of), but I had a modest heart attack in December. I’m also in a clinical trial of an HDL-boosting drug, but won’t know until 2016 whether or not I’m on the drug or a placebo. I suspect from the recent improvement in my (generally reviled) singing that it’s a Placebo Domingo.

Even though their (dubious) benefits have only ever applied to men, I have had no shortage of doctors trying to persuade me that I should take them anyway. When I politely decline, the look at me as though I am someone who believes that UFOs are landing all over the place and subjecting people to anal probes.

If pressed, I do tell them why. Not that (to my knowledge) it has ever encouraged them to do any further research.

Clinical guidelines are a two-edged sword, and those who formulate them should be very wary of being too prescriptive. I don’t discount Judith’s points about conflicts of interest and so on, but this sort of conspiracist thinking obscures the core of the issue. Clinical guidelines are essentially a way to avoid making individual judgements, with your ass being covered if you are wrong. What is the point of having highly-trained doctors, if a computer can spit out what needs to happen given a particular set of circumstances?

You are projecting Rob Enron Bradley’s ad hominem smears of climate scientists on to me. Rob Enron Bradley knows all the fallacious arguments in the book, seeing as how he was Public Relations Policy director at Enron.

For Rob Enron Bradley to compare citizens concerned about climate change to the Enron scum caught on tape, is arrogant beyond belief.

I point this out and you think we should just ignore these connections?

Like Craig Loehle’s one degree of separation between his outfit and Koch Industries?

There is a guy John Mashey that documents all the atrocities in the denial industry. Go to SourceWatch, DesmogBlog, Merchants of Doubt, etc. It’s not tough.

Yes, John Mashey “documents all the atrocities of the denial industry,” real and imagined. And the ones he fabricates because he can’t read simple sentences. And the simple lies he promotes to stroke his ego.

Rob Bradley Jr. said:
”
Indeed, climate alarmism is looking more and more like the Enronization of science. The alarmists are the smartest guys in the room, calling their opponents “deniers.” Like Enron, climate-science “profit centers” are government dependent.
”

Like I said, if Rob Bradley wasn’t so inept to make a link to this letter that he apparently wrote, he likely wouldn’t be feeling the blowback for the massive dose of projection he has produced.

I have a family member who got diabetes after being given steroids as a treatment. It was never clear if the steroids caused it or if the condition was already developing, but it’s worrying to think one could develop a permanent medical condition based upon bad science propped up by a false “consensus.”

Telling whether or not diabetes was caused by steroids is often very difficult. Steroids can cause diabetes, but steroids is also used to treat conditions which can lead to steroids in and of themselves.

Well, you mean ‘diabetes in and of themselves’. Of course, it was a joke about manifold causation, but the butterfly didn’t think his wing spasming was funny.

From what little I know, steroids raise blood sugar. Whether a raised blood sugar is diabetes or not(certainly not necessarily), and whether or not a raising of sugar from steroids can actually cause diabetes are difficult questions, partly so because there are so many causes of diabetes and so many possible instigators of raised blood sugar impacting the body at any given time.

It was most likely co-incidental in the case of your family member.
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Anyway, steroids do cause higher blood sugar levels. There’s even a condition called something like steroid induced diabetes, which is diabetes a person gets during a steroid treatment that goes away after the steroids are stopped.

That’s not what I was talking about though. Steroids can also damage the pancreas, leading to diabetes. That’s especially true if the pancreas is already weakened. In that case, the steroids serve as an additional stressor. The steroids aren’t the cause, but they contribute.

I have posed this query to several friends who are medical professionals,
The response which is easily the mode: ‘The (medical) consensus eventually becomes the opinion of the loudest SOB in the room’.

For me, when I look to see if a committee is likely stacked, I look at who is making the “call” as to membership. The “who” (nominating committee) frequently will be the person or persons with an agenda. Parsing out the agenda for the nominator(s) is helpful to me in deciding if the guidelines or consensus statements are a step forward.

For NIH clinical guidelines there is usually a mixed bag of statements most of which are true as far as being known. The guidelines become skewed when the actual recommendations get made: do this and not that.

From my own experience, I learned that consensus statements’ agendas were to be used as a bludgeon to enforce the behavior of the many for the benefit of the few; not all motivated by greed, rather, by good intentions.

There is a startling symmetry between the IPCC consensus statements and NIH clinical practice guidelines in formulation, intent, and application.

Well said. As I noted in my post about statins (above) the problem is inherent in the creation of groups of people who lay down “guidelines”. Simply because they exist, they will be eyed and infiltrated by people who want to game the system.

But, the bigger issue is that “guidelines” provide incompetent practioners with a shield; reduce the discretion of competent practitioners; expose practitioners who breach the “guidelines” to litigation, irrespective of the evidence; and perpetuate fallacies (such as that statins should be prescribed for women) even in the face of the evidence.

Although the analogy is apt, there are also significant important differences.
Apt is the problematic nature of ‘consensus’ and how it gets formed. There are many unfortunate modern medical examples of harmful consensus treatment protocols in addition to steroids for acute spinal trauma (the theory was that paralysis is a sequelae of inflammation that steroids reduce). For example, HRT for post menopausal women.
Less apt is the fact that many medical SOP’s exist on which there is little scientific controversy, from hand hygiene (semmelweis) to preventative vaccinations to…, while with AGW there aren’t countervailing examples with unequivocal net benefit to offset the occasional error.

An important difference is that medicine follows up with outcomes, and reverses course when new data appear, as above. So far there is no evidence of that in AGW, for example in AR5 SOD. An unfortunate supposition is that AGW has become more politicized ( read hike ked by other agendas) while physicians still focus primarily on health and healing.

One of my favorite examples of the quality of “medical consensus” is salt.

Good.

Bad.

Actually, it is good.

Nope, you haven’t been paying attention. It’s bad alright.

Oops, I see it is back to being good.

Ever wonder what would happen if aspirin had just been discovered? I remember reading somewhere that it would never be allowed on the market, as researchers still don’t understand much about how it works. Kinda like clouds.

We have little kids. When the first was almost born, we’d read that we “must” put her to bed on her stomach, but we’d also read that we “must” put her bed on her back. In both cases, failure to comply was a risk of death!
So we asked the Pediatrician, the OB and L&D nurses and every one of them laughed and said some variation of “I don’t know which it is this week. Whatever it is, it will be the opposite next week. Studies!’

My favorites are butter vs. margarine, eggs, trans fats vs. palm oil, etc. For years the govt. thought margarine was better for people than butter. They also said eggs were not healthy and should be limited. A lot of people to this day avoid eggs and butter when they are actually extremely healthy. Now that trans fats are bad (this is true I think) some have switched to palm oil which is now verboten due to rain forests and orangutans. I think McDonalds has been forced to switch about 3 times the type of oil it uses for its fries and each time they switch, apparently their new choice is the worst thing ever for health or for the environment.

Publish-or-Perish is the great intellectual disgrace of our era, and the trash mentality behind it serves the climatariat admirably.

I believe we should make like the alarmists, only sooner. To keep their particular academic racket sustainable (ugh, that word!) they need to make room for new junk. Consequently, they dismiss or bury the various “papers” and “studies” after just a few years. (You know the drill: The science is still settled, only more so. New findings indicate that “it” is worse than we thought etc etc.)

I just get in early and ignore the rubbish straight away. That’s the only diff between my skepticism and their alarmism.

Mr Istvan::
You are more optimistic than I concerning the ability of medicine to measure outcomes and then change course. One problem is the size of benefit that justifies some degree of harm or cost, either financial or social. Another is how benefit is measured, e.g., markers such as blood cholesterol as opposed to prolongation of life. And most important is how these “benefits” are presented to physicians, i.e., through Drug Representatives or by accurate data.
Finally, the physician must (at least should) make a decision, not in terms of guidelines but for a particular patient in a particular circumstance. Often that is not easy.

Mr. Sutter, I agree with your observations about incentives along the medical ‘value chain’, and called out some specific situations in a recently published book.
BUT in my personal experience, and despite media attention to a venal few physicians who ignore their Hipocratic Oath and over prescribe or over procedure to enrich themselves (and lest this seem hypothetical, it almost happened to my significant other despite recommendations from a former dean at Johns Hopkins, until I vigorously intervened to insist on a second opinion at Mayo since nothing the esteemed recommended doctor urged made sense given her medical history and his earlier interventions) most physicians really care and really try to do their best for their patients.

On the public record, the same basic good intent cannot be inferred for many prominent climate ‘scientists’ including Hansen, Mann, Jones, Schmidt, Trenberth, Dessler, Marcott,… Our gracious host, Richard Lindzen, the Pielkes, and a few courageous others like Australia’s Glenn Paltridge are outstanding exceptions proving this unfortunate observational general rule of thumb about climate science. Too many apparently just follow the funding money and/or the political agendas, rather than the observational data and what it suggests for improved scientific understanding.

Flawed Theory that is endorsed by a Consensus Group that causes harm to people is something that happens, time and time again. We need to pass some laws that say Consensus cannot be used for anything important to us.

So we want regulations on how people should agree? We want to control the way people control narratives by regulating the way agreements between groups of people are made. How would that work for consensus type organizations such as ASTM? How would that work for organizations such as AMS? Do you think specification writing is important? You don’t think consensus should be reached when writing specifications? Further, there should be laws regulating against such activities and organizations? I thought you were an Engineer? Maybe you need to think about that idea again… Just a little.

There is no hidden agenda or ‘Big Pharma’ payoff in the use of steroids for trauma, as all the drugs are cheap generics.
The problem is that people are people and rats and mice aren’t; they are models of people.
You can drop a standard weight, a standard drop with a standard size wedge onto a population of rats and get a quite tight outcome with respect to outcome, with respect to spinal cord damage.
You can try different drug treatments on the rats and find a better outcome with steroids, as these stop the inflammatory response and the secondary, immunosystem, wave of cord damage.
The you trial it in humans.
Here is the problem; You can not have a powerful blind, randomized, trial of human spinal cord injury.
You can have a patient present at A&E, diagnose the condition, ask the person if they want to be in a trial, do the paperwork, and give them drug or placebo.
Then at 6 months you work out if the patient did better, the same or worse than you expected. You do not know, a prior, if your patient is going to be in a wheelchair for life or back to playing basketball next season.
It is very easy, by chance, for a study to find benefit of drug over placebo just from low patient numbers in the trial. This is always compounded when clinicians/scientists have to use their judgement as to if the outcome is better or worse. The reason being that clinicians & scientists are liars, full time, non-stop liars. They cannot help it. They build studies to try their best to make it impossible to lie, but that nasty expectation of the good subconscious back stabs them mercilessly.
One can look at images in the scientific journals, images of control tissues. Almost always their is in center field is an inhomogeneity; typically a blood vessel or tissue type boundary. This is also the case in observing cultured cells, they take images of confluent, and not clustered cells, because the image is more pleasing to the ‘eye’.
The reason is that people looking through microscopes are drawn to defects in organs and ordered patterns in chaos , they have great problems in disciplining themselves to take boring or completely truthful and representative images, even if they are supposed to be taking boring or jumbled images.
Scientists are human, they are supposed to recognize this, and try their best to design their experiments and analysis to remove as much of their own bias as possible.
Anyone can ‘prove’ an hypothesis; the posters who ‘prove’ that back radiation is incompatible with the laws of thermodynamics are proof of that.
If you look for hidden heat in the oceans, you will find it, because it is possible to treat the data to give heating or cooling, depending on your bias.
If you look for heating or cooling in tree-rings, you will find it, because it is possible to treat the data to give heating or cooling, depending on which trees you pick and which you discard.

‘Simply put, if you’re attracted to ideas that have a good chance of being wrong, and if you’re motivated to prove them right, and if you have a little wiggle room in how you assemble the evidence, you’ll probably succeed in proving wrong theories right. His model predicted, in different fields of medical research, rates of wrongness roughly corresponding to the observed rates at which findings were later convincingly refuted: 80 percent of non-randomized studies (by far the most common type) turn out to be wrong, as do 25 percent of supposedly gold-standard randomized trials, and as much as 10 percent of the platinum-standard large randomized trials…

Still, Ioannidis anticipated that the community might shrug off his findings: sure, a lot of dubious research makes it into journals, but we researchers and physicians know to ignore it and focus on the good stuff, so what’s the big deal? The other paper headed off that claim. He zoomed in on 49 of the most highly regarded research findings in medicine over the previous 13 years, as judged by the science community’s two standard measures: the papers had appeared in the journals most widely cited in research articles, and the 49 articles themselves were the most widely cited articles in these journals. These were articles that helped lead to the widespread popularity of treatments such as the use of hormone-replacement therapy for menopausal women, vitamin E to reduce the risk of heart disease, coronary stents to ward off heart attacks, and daily low-dose aspirin to control blood pressure and prevent heart attacks and strokes. Ioannidis was putting his contentions to the test not against run-of-the-mill research, or even merely well-accepted research, but against the absolute tip of the research pyramid. Of the 49 articles, 45 claimed to have uncovered effective interventions. Thirty-four of these claims had been retested, and 14 of these, or 41 percent, had been convincingly shown to be wrong or significantly exaggerated. If between a third and a half of the most acclaimed research in medicine was proving untrustworthy, the scope and impact of the problem were undeniable.’

I have quoted this before – but it seems appropriate. Climate research is non randomized. Is 80% incorrect? 100% of blog science?

Well, I think that the stent increasing the blood flow through my central artery from 10% to 58% of nominal capacity is probably a good idea, and I’ll keep taking the low-dose aspirin until I get solid advice to the contrary. Not knocking the excelent Ionnaddis, though, perhaps these weren’t amongst the discredited findings.

Chief Hydrologist | July 10, 2013 at 4:59 pm said: ” if you’re attracted to ideas that have a good chance of being wrong, and if you’re motivated to prove them right, and if you have a little wiggle room in how you assemble the evidence, you’ll probably succeed in proving wrong theories right”

CO2 has been known to be an important GH gas since the middle of the 19th century.

In Pre-industrial times the level of CO2 in the atmosphere was 280ppmv.

Now, its almost 400 ppmv

If we carry on burning fossil fuels as normal, the so-called business-as-usual scenario, the pre-industrial level will at least double, to 560ppmv or more, by the end of this century.

The consensus scientific opinion is that this will increase global temperatures by between 1.5 and 4.5 degC.

We could be lucky. It could be on the lower end of the scale. We could be unlucky. We could end up on higher end. Some scientists think, including one Prof Judith Curry, that the higher end could be more like 6C or even 10C.

Is it better to trust to luck? Or is it better to do what is possible to keep CO2, and other GH gases, under some control?

Coteries can be wrong… you bet. Especially in the field
of climate – models – and – narratives – ‘science’. Why,
that’sa meadow of sprouting projections ,hmm .. more
of a wilderness than meadow, i’d say.
Bts

Gad, Beth, I wuz wundering why we were counting calories instead of foraging, and then I see the metric is in coteries. A stat infusion in the roasting fleshy offering gives Yamal a la McIntyre, fit food for the gods and Gaia. Serve with theobromine, Ha, Chokola!
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‘Sensitive dependence and structural instability are humbling twin properties for chaotic dynamical systems, indicating limits about which kinds of questions are theoretically answerable. They echo other famous limitations on scientist’s expectations, namely the undecidability of some propositions within axiomatic mathematical systems (Gödel’s theorem) and the uncomputability of some algorithms due to excessive size of the calculation.’

280 to 400 ppm is almost exactly half of the temperature increase of 280 to 560 ppm CO2. So we have observed half the ‘Thermogeddon’ already.
The question you should ask yourself is do we destroy the economy, and sacrifice the the people living in the Third World for a century of poverty to stop it becoming a bit warmer?

Web, are you misinformed or stupid?
I only ask as Egypt has enormous natural gas resources, vast amounts undeveloped.
Are you aware that although Egypt is a third world country, not all third world countries are Egypt?
Are you also aware that when the excrement hits the ventilation system that it is the poor, and not the rich, who suffer the most.
I don’t give a damn about the levels of atmospheric CO2, it makes no difference to life on Earth in the near or far future. There is no ‘Thermogeddon’, no 3 degrees of warming and no ‘we must reduce our fossil fuel usage’.
What we have is an array of people who just hate the society they live in, in particular, and actual living people in general, who want to sculpt a Utopian humanity living in ‘harmony with nature’.
Thirty years ago you would be extolling the virtues of the Soviet Union and Mao, using your maths skills to show why they were making more tractors that the USA.
With you this CO2/Climate Sensitivity/Temperature/Tipping Point stuff is just a way for you externalize your self-loathing.

DocMartyn,
Massive amounts of projection on your part to accuse me of “self-loathing”. This is almost as bad a case of projection as upthread where former Enron honcho Rob Bradley accuses “climate alarmists” of being like Enron. That is projection folks, and like Rob Bradley, you DocMartyn are actually the self-loather. Psych 101.

“Egypt A Peak Oil Revolution
By Binu Mathew
What is happening or just happened in Egypt could be the first Peak Oil revolution which is sure to replicate many times over in many countries around the world. The root cause of Tahrir I as well as Tahrir II was the economic condition of Egypt which put the middle class and the working classs under severe stress and made life unbearable for them.

Tahrir II was directly caused by the widespread fuel shortages and high energy prices. It is not just the craving for democracy or the opposition to Muslim Brotherhood, that led to these revolutions, but the desperation of the people. In both these revolutions the army took over and people seemed to be happy! The underlying message is that when citizen’s life hit a dead end, people will throw away the rulers. New one will come and that one too will be thrown away sooner or later. Will it make life better for them? No.
“

It would seem that peak oil goes into the dustbin of history along with Erlich’s population bomb, the AIDS crisis, eugenics, and vertebraeplasty as theories that appealed to those whose emotions dominate their rational powers. Webby of course will never close his web site. He runs it from his mothers basement.

“You can only say this if , and when, the Earth is in thermal equilibrium”

The Earths temperature is never in equilibrium; the ‘average’ temperature is a steady state. Steady states are quite different from equilibria and pretending one is the other is quite wrong; you may as well treat a helicopter as a helium balloon as they both float in the air.

CO2 has been known to be an important GH gas since the middle of the 19th century.

No it hasn’t, Tyndall thought it insignificant compared with water in the atmosphere and Arrhenius got it muddled with carbonic acid, that is, he included water in his measurements.

Water has an very high heat capacity, which means it takes in a lot of heat energy before it shows any change in temperature. Carbon dioxide has practically zilch heat capacity, which means it absorbs and releases heat instantly.

In Pre-industrial times the level of CO2 in the atmosphere was 280ppmv.

Now, its almost 400 ppmv

Not proven. Callendar/Keeling cherry picked numbers. Stomata data also show that this 280 ppm figure a figment of the creative agenda driven imagination.

The “Keeling Curve” shows no correlation to temperature changes during its reign, it certainly shows that carbon dioxide does not drive temperatures.

And, measuring the mythical “well mixed background” which was a concept invented by Keeling, from the top of the worlds biggest active volcano surrounded in active volcanoes and thousands of volcanic activity earthquakes every year in warm seas, the place of choice for a scam artist to measure “carbon dioxide unadulterated by local production”.

Is it better to trust to luck? Or is it better to do what is possible to keep CO2, and other GH gases, under some control?

Stick to the science, prove that trace amount carbon dioxide can heat up my attic floor, that doubling this can raise the temperature of my attic floor several degrees.

Show me the lab tests, and comparisons with other materials used for lagging attics to slow down heat loss.

This is a brilliant comparison. However, like with anything, there is subtlety that makes things even more relevant and I’d like to point out where climate scientists have it frequently wrong in public perception and in actions.

The practice of medicine does not fully rely on guidlines and clear criteria. Medical diagnosis is frequently rule out. Sometimes clear diagnoses can be made. But once a diagnosis is settled on, there are options given to a patient. Say a patient receives a diagnosis of ductal carcinoma in situ. There becomes a variety of treatments that are proposed, with costs and benefits, and it is up to the patient to decide what is best. (I am talking US healthcare here).

The “standard or care” frequently does not involve what is to be done. The SOC does not call for a surgeon to automaticallly perform a radical bilateral mastectomy. But a patient may opt for this. And it is within the patient’s right to choose between a lumpectomy or mastectomy or other treatment. Whatever treatment is done must be performed within the standard of care.

Climate science consensus – unlike health care practitioners – come from a certain position that would, say, demand that radical mastectomy is the only option. And, anybody who disagrees is a tool.

Physicians are always tasked with managing patients who make choices that they may believe to be foolish. But, as all physicians know, individual judgments are based on individual values. And for a physician to exert her will over the values of others is not considered to be malpractice.

Recognition of all sides is important. This patient needs a team. Internist. Surgeon. Oncologist. Psychiatrist. All to implement the desire of the individual and not to inflict their viewpoints on the patient.

The decision to follow even non-mandatory “guidelines” by the medical profession is in large part due to the desire to avoid medical malpractice suits. A material element in every professional negligence case is that the defendant breached the standard of care.

If you follow the community standard of care, you for the most part can’t be found liable. Widespread guidelines, no matter how ill advised, can set that standard.

In the climate context, you can’t be sued no matter how outrageously bad your standards are. So not surprisingly, there are none.

God help climate scientists if their progressive brethren in my profession ever get the courts or congress to recognize scientific malpractice as a tort.

After having three epidural steroidal injections this year for a lower-back problem that weren’t helpful, I found this post interesting. I’m not certain that the focus on how consensus is achieved was retained.

‘Whether the human animal committed a blunder when — in the course of his evolution — he resolved to stand on his hind legs and face the world in an upright position, is a question I should not presume to discuss in all its phases. Personally, I am just as well satisfied not to be walking on all fours. But when this animal tipped his viscera from horizontal to perpendicular he incurred a flock of disabilities. They begin to show up as soon as he learns to walk.’

Judith, your summary above of the Lanzar paper reminds me of a similar problem in Australia. Apparently here Opfhalmologists have a standard practice for checking visual acuity. They use local anasthetic drops to dilate the pupils of the eyes for internal examination. While still under the local anasthetics they then proceed to try to find the best corrective lens for each eye which is unlikely to give correct results, Certainly with me because my eyes no longer focus correctly. Because the results of such examination might be used by the Road Transport Authority to deny a driver’s licence to an individual, it can have serious economic consequences.

‘High dose steroids’? Well, forget the temperature of the porridge; Papa’s bowl is dyspeptically large, Mama Bear’s may be easier on the side effects, but Baby Bear’s aliquot turned into a kumquat @ Midnight and ran off with the Three Blind Mice.

Show me the studies showing no benefit from the correct dose of steroids, according to studies to determine the correct dose. Peer review? I’ll take anecdotes, enough of ’em.

There may be an unexplored analogy here with the clinical guidelines of 1990 for high dose steroids in spinal cord trauma. No doubt(I’m guessing) the Poobahs wanted a simple formula, easily remembered by stressed clinicians dealing often with other casualties and other organs involved besides the spinal cord. The need for a simple message quelled the dissenting voices.

Pretty soon I can work this up into a full-fledged metaphor, but probably not up to the sonnet level. That takes craft.
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Let’s be sure to recognize that erroneous medical consensus is not always the result of conflict of interest. The misunderstanding of the cause of gastric ulcers, and the resulting inappropriate care, was a longstanding “standard.” It took heroic effort on the part of the discoverer of the primary cause (Helicobacter pylori) for the consensus to be broken. Even after that, for a long time, many practitioners adhered to the old theories and treatments.

Also… while the gravity of medical consensus driven decisions is immediately understood, the gravity of those in the climate change world are also grave. If the alarmists are right, mankind is in great danger. Whether they are right or wrong, continued meddling in the economic systems represents both a probability of increased suffering and death among the most poor, along with potentially disastrous geo-political consequences which effect billions.

Judith, This is a great post. I’ve been emphasizing the parallels between medicine and climate science ever since I started commenting here. The sources of bias are to a large extent the same. Pervasive positive results bias, the overlap of political, monetary, and deep personal unscientific biases cause serious problems in medicine. The difference is that medicine recognizes and studies the problem. Climate science does not. Climate science is still dominated by a clique (the Team) that like St. Thomas Aquinas knows it all and proves it all and dispenses its dogma in the official organ of orthodoxy, ie., Real Climate, where disagreeing scientific comments are suppressed but the most bigoted libels and political bias are allowed. The most obvious fingerprint of this approach is the in line responses, often sentence by sentence. It is exactly the style of Aquinas and is more suited to dogma than science. Until climate science recognizes that it has a problem, it deserves derision and ridicule and to not be taken seriously. More open blogs such as this one allow commenters to state their position. Then the proprietor responds in a separate comment. This allows both sides to be at least states clearly.

Annals of Statistics did it right. They published a paper by McShane and Wyner on statistical significance of paleoclimate reconstructions. Then they published a response from the Team and a reply by McShane and Wyner and also a number of comments on the dispute. This way both sides get to be presented and others can decide for themselves.

Real Climate’s thread on Briffa et al 2013 is a classic contrast. Comments are censored and the sentence by sentence Nurse Ratchet correction method is quite prominent. The ruler is hauled out and used to rap the inferior classes on the knuckles. It seems to many third part observers that in fact Briffa et al repudiates earlier hockey stick results, but this is simply passed over in silence while ad hominum attacks on McIntyre are simply stated (without sourcing) so that no one can verify who is actually right. A classic tactic of those “who seek not the truth, but their own advantage” to quote Hobbs.

‘Professor Bob Carter has been a key figure in the Global Warming debate, doing exactly what good professors ought to do, challenging paradigms, speaking internationally, writing books, newspaper articles, and being invited to give special briefings with Ministers in Parliament. He’d started work at JCU in 1981 and served as Head of the Geology Department until 1998. [UPDATE: to clarify, sometime after that he retired]. Since then he’s been an honorary Adjunct Professor. All JCU had to do was to approve an extension of this arrangement, giving him library and email access, at little cost to them, and he could have continued to help students and staff, provide a foil, a counterpoint, and keep alive the spirit of true scientific enquiry. (Not to mention his continued speaking, books, and influence on the National debate).

Instead every person in the chain of command tacitly, or in at least one case, actively endorsed the blackballing. Each one failed to stand for free speech and rigorous debate. In the end, JCU didn’t even make any effort to disguise the motive. The only reasons given were that the staff of the School of Earth and Environmental Studies had discussed the issue (without any consultation with Carter) and decided that his views on climate change did not fit well within the School’s own teaching and research activities. Apparently it took up too much time to defend Carter against outside complaints about his public writings and lectures on climate change. (Busy executives don’t have time to say “Why don’t you ask Carter yourself?” or “We value vigorous debate here.” Presumably they are too busy practising their lines and learning the litany?’

This is the reason why, if you are ill in the U.S., you want to be treated in Rochester, MN or Salt Lake City or Cleveland or…

Some medical institutions follow EVIDENCE BASED MEDICINE, meaning they analyze the outcomes of many patients with the same disease and develop treatment protocols based on which treatments yield the best outcomes. They do this as an on-going process, constantly collecting and analyzing the evidence and using it to adjust their protocols.

“Some medical institutions follow EVIDENCE BASED MEDICINE, meaning they analyze the outcomes of many patients with the same disease and develop treatment protocols based on which treatments yield the best outcomes”
Ah, the joy of simplicity.
” the same disease”
What does that mean?
What is a ‘disease’?
Do you mean a descriptive noun that encompasses a collection of phenotypic observations?
I have the worlds largest collection of primary glioblastoma cell cultures in my nitrogen freezer. I have looked at more than twenty primary cultures in some detail.
They are all different.
Most often a disease is no ‘a disease’, but a description of a pathology.

Yes, K scott denison,
A bit like the empiric based historical on record climate,
If the Thames froze in … if a glacier swallowed a village
in the Austrian Al[ps in ,,,
EVIDENCE BASED … the records had no reason ter lie,
no grants pending, no political agendas regardin’ crops
or CET temperature records, etc far as we can see.
Bts

The freezing of the Thames and village’s under glaciers are anecdotal; tree-ring widths and bore-hole water temperatures are data.
The new updated US temperature will indicate that the dust bowl conditions of the 30’s were due to snow.

I had an email from a Chinese company a couple of weeks ago. They offer to rapidly supply either gene knockout or knockin mice; the kicker was in the cost, $5,000 for each strain. The price of molecular biology is insane.
I can get a tumor/white blood cell DNA comparative genomic analysis, looking at the changes in 20,000 genes, for $3,500 and in 10 weeks.
A decade ago that would have been closer to a billion and taken a year.

Now yer talkin’ my language, Doc. You can cut & paste genomes together in desktop laboratories. You can have a million test tubes on a wafer smaller than a postage stamp with reactants moved around by electrostatic charges and results read off by laser. All without human touches.

So here’s the deal. Before too much longer lab automation is going to make it so some modern version of me in bioengineering can sit down at an engineering workstation, cobble up a bacterium with a genone that never came close to existing in nature, and have a buttload of cultures in a target test environment hopefully doing whatever you designed them to do or if not quickly revealing what you need to know to correct the design issues. You can do that easily, cheaply, and quickly.

I’ve seen technology progress like this before. Think biological version of Moore’s Law.

Found problem in a patient that can be connected by a little gene therapeutic magic delivered to each effected cell in the body? It’ll be like the iPhone, Doc. There’ll be an app for that. Drugs are like using a bulldozer to make a Cobb salad. You really want finer instruments that are smart enough to recognize their targets and make changes with molecule by molecule precision. That’s where we’re headed in the short term. In the long term – I dunno – immortality, artificial everything, paradise in artificial reality? Maybe the new Garden of Eden is in The Matrix. Hell maybe that’s where the old one was. ;-)

Vaughan Pratt | July 11, 2013 at 2:20 am |
writes
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Unless you have a foolproof process for this problem, we’re looking at a fundamental flaw in Crichton’s line of reasoning here.
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We have a completely foolproof process. It was “invented” by Galileo, and the developed by Newton. It is called measured, empirical data. It is the basis of the scientific method. Think Michelson/Morley. Think Richard Feynman.

As I have noted mamy times, the problem with climate science is that we cannot do controlled experiments on the atmosphere. The atmosphere is non-linar, chaotic, etc. etc. This was the fundamental problem facing the warmist; ab initio. They tried to end run the problem by claiming that their models were the equivalent of experimental data. Model outputs, and hypothetical estimations, never were, still are not, and never will be the equivalent of empirical data.

This is the hoax the original warmists pulled off. They must have known that there could NEVER be the empirical data to prove the hypothesis of CAGW, so they invented all sorts of pseudo-scientific ruses to fool our politicians and the public that they were following the scientific method; when they weren’t.

I have said it so many times people are tired of me. I am sorrty. But the Supreme Court of Physics is the empirical data. Period.

I think a controlled experiment is possible. For example, relocate the emission point from a coal fired power plant to a pristine area (desert, offshore, forest…), which should create an artificial, ‘rural’ CO2 dome around the emission point, with increased CO2 concentrations closer to it. Then measure if the higher CO2 concentrations change anything (temperatures, surface heat fluxes…). It shouldn’t be that expensive.

Doctors who are sceptical about the scientific basis of clinical guidelines have two choices: they can follow guidelines even though they suspect doing so will cause harm, or they can ignore them and do what they believe is right for their patients, thereby risking professional censure and possibly jeopardising their careers.

Not to mention jeopardizing their patients’ health. As with placebo-controlled clinical trials, there is no a priori way to know whether the placebo (“standard”) group or treatment (“innovative”) group is exposed to the most risk. However, it is almost always a mistake for a Dr to use his or her judgment based on a small biased sample when there is evidence from a larger and less-biased sample. All sources of knowledge will be wrong from time to time, but small biased samples are not to be trusted more than larger, less biased samples.

Malpractice avoidance. Procedural medicine. Assembly line hospitals. Can’t fault anyone who “goes by the book”. Medicine isn’t especially unique. Everyone exposed to torts has a book to follow to limit exposure.

It.seems like a process by which a clinian can express their skepticism in a particular decision would be advantageous. It would then be the responsibility of the governing body to either act or not based on the weight of growing sceptic views.

Conflict of interest from industry’s science well enough understood, but somehow conflict of interest from the state’s science is routinely glossed over, even though the state is vastly bigger and of course far more self-interested and ruthless – climate science the obvious case in point here.

Conflict of interest recommendations made by the InterAcademy Council are being addressed by the IPCC in a minimal way.

So state scientists are being asked to assess the state’s (patently obvious and monumental) conflict of interest. It just beggars belief.